Jeremiah Head-to-Toe Competency Scenarios Terms in this set (12) 65-year-old male patient with history of depression reports fatigue and dizziness. Safety and Professionalism, Vital Signs General Survey 1. LOC (A+O) 2. Any sensory deficits?

Jeremiah Head-to-Toe Competency Scenarios Terms in this set (12) 65-year-old male patient with history of depression reports fatigue and dizziness. Safety and Professionalism, Vital Signs General Survey 1. LOC (A+O) 2. Any sensory deficits? (Glasses, contacts, hearing aids) 3. Comment on pt's speech 4. Note if patient follows directions well 5. Comment on mood and affect (Determine cause of negative mood: loss of job, family problems, etc.) 6. Assess for spiritual needs. Recommendations: Referral for counseling/mental health services. 24-year-old male patient with history of DM type 1 and reports rash. Safety and Professionalism, Vital Signs Integumentary 1. Blood sugar 2. Ask about itching or skin irritation 3. Inspect skin for pallor, cyanosis, erythema, swelling, rashes, bruising, skin breakdown, or wounds 4. Check between toes 5. Inspect nail beds for clubbing/discoloration 6. Assess skin turgor Recommendations: Diphenhydramine or oral steroid (ex: prednisone) 59-year-old female patient hx of tobacco abuse and reports blurred vision for 1 hour. Safety and Professionalism, Vital Signs Cardiovascular 1. Chest pain? Palpitations? Dizziness? Hx of MI? 2. Ausculate 5 cardiac areas (S1 and S2 present?) 3. Apical pulse (60 seconds) 4. Cap refill on fingers and toes 5. Palpate radial, dorsalis, posterior tibial pulses 6. Check for edema Neuromuscular 1. FAST (facial drooping, arm drift, slurred speech, time) 2. Demonstrate active or passive ROM of upper extremities 3. Assess gait for lower extremity ROM 4. Test sensation in upper and lower extremities 5. Assess/rate grip strength 6. DTR of one tendon bilaterally 7. Check plantar flexion/dorsiflexion against resistance HEENT 1. Inspect head and face for symmetry (stick tongue out, puff out cheeks, smile with teeth) 2. Check eyes for abnormalities, use penlight to assess PERRLA 3. Test EOMs (6 cardinal positions) 4. Inspect mouth and oral mucosa and palpate lymph nodes Recommendations: Referral for vascular specialist for venous study of carotids. 10-year-old female patient hx of asthma and reports wheeze. Safety and Professionalism, Vital Signs Respiratory 1. Cough/sputum? 2. Auscultate all posterior/anterior/lateral lung sounds 3. Smoking hx? 4. Shortness of breath? 5. Meds? Inhaler? 6. Inspect respiratory effort 7. Symmetrical chest expansion? 8. Dyspnea? Recommendations: Albuterol nebulizer 55-year-old male patient hx of hyperlipidemia, hypertension, and smoking reports chest pain. Safety and Professionalism, Vital Signs Cardiovascular 1. Ask pt about palpitations, dizziness, hx of MI 2. Chest pain assessment (OLDCARTS) 3. Apical pulse 4. Auscultate 5 cardiac areas 5. Check peripheral pulses (radial, dorsalis, post tib, etc) 6. Cap refill on fingers and toes 7. Check for peripheral edema (pitting or non pitting?) Head-to-Toe Competency Scenarios 34-year-old female patient hx of lactose intolerance reports vomiting and diarrhea x 12 hours. Safety and Professionalism, Vital Signs Abdomen/Gastrointestinal 1. Onset of symptoms? 2. Frequency of vomiting? 3. Have you had lactose recently? 4. Any nausea r/t vomiting? 5. Abdominal pain? 6. Inspect abdomen (flat, distended, rounded) 7. Auscultate bowel sounds 8. Palpate all 4 quadrants 9. Percuss for CVA tenderness Recommendations: IV fluids and labs 59-year-old male patient with history of BPH report unable to void x 10 hours. Safety and Professionalism, Vital Signs Genitourinary 1. Time of most recent void 2. Urine characteristics (color, difficulty, clarity, odorous, blood) 3. Urine stream (forced, split) 4. Hx of difficulty urinating 5. Current hydration level (assess skin turgor) 6. Hx of this problem? 7. Palpate for suprapubic tenderness (urinary retention/distention?) Recommendations: Catheterize, monitor I&O 45-year-old male patient reports back pain after fall from ladder. Safety and Professionalism, Vital Signs Neuromuscular 1. Demonstrate active ROM of upper extremities. 2. Test sensation in upper and lower extremities. 3. Assess and rate grip strength. 4. Demonstrate DTR of one tendon bilaterally. 5. Check plantar flexion/dorsiflexion against resistance. 6. Assess gait for lower extremity ROM. Recommendations: X-ray of lumbar-spine, NSAIDs (like ibuprofen), and pain meds 65-year-old female with emphysema reports dyspnea. Safety and Professionalism, Vital signs Respiratory 1. Any cough/sputum? SOB? Smoking history? Inhaler? Medications? 2. Inspect respiratory effort, symmetrical chest expansion, and note any dyspnea 3. Auscultate breath sounds posteriorly, anteriorly, and laterally. 4. Verbalize or demonstrate that auscultation should be done directly on the skin. Recommendations: Chest x-ray r/t concern of upper/lower respiratory infection; may need antibiotics 60-year-old male with history of atrial fibrillation reports swelling in lower leg. Safety and Professionalism, Vital signs Cardiovascular 1. Ask: Any chest pain? Palpitations? Dizziness? Hx of MI? 2. Auscultate all 5 cardiac areas with diaphragm. S1 and S2 present. (Regular rate/rhythm? Any adventitious sounds?) 3. Assess apical pulse (for at least 60 seconds) 4. Check capillary refill on fingers and toes 5. Palpate radial, dorsalis pedis, and posterior tibial pulses and assess for amplitude and symmetry (+1-+2 = weak, +3 normal, +4 bounding) 6. Check for edema in lower extremities (pitting, nonpitting) Recommendations: Venous ultrasound and D dimer Safety and Professionalism 1. Appropriate appearance (uniform, hair up), perform hand hygiene before beginning 2. Introduce yourself and explain role (student nurse) 3. Provide privacy and attend to patient comfort throughout exam. Explain procedures, give clear instructions, and demonstrate active listening. 4. Check two pt identifiers (confirm ID band with pt's stated name and DOB) 5. Protect back with proper body mechanics throughout exam Vital Signs 1. Blood pressure 2. Temperature 3. Radial Pulse (30 sec) 4. Respiratory Rate (30 sec) 5. O2 sat 6. Ask: Pain assessment using OLDCARTS